(a) Sufficient Staff | F353

Federal regulations have almost no requirements for accelerating nursing staff according to the size of the facility or any other resident characteristics. Federal requirements call for a sufficient number of staff to accomplish the care plans, one RN in an 8 hour period (largely during the day shift), one licensed nurse (i.e. an RN or an LPN) on every tour of duty, and a Director of Nurses (DON) who is an RN. The only reference to size of the facility is the proviso that the DON may not count as the registered nurse on duty if the facility has 60 or more beds. Federal law also requires that dedicated assistants with feeding not count as part of the nursing staff if the State has requirements as to the ratio of nursing staff to residents.

Thirteen (13) States have no numerical ratios for nurse staffing, although some of these states require more licensed and/or registered nursing presence than is required by federal regulation. The remaining States have established a required ratio of staff to residents. In those cases, the State almost always specifies the proportion of nursing time that must be fulfilled by licensed staff, and some States further differentiate between RN and other licensed staff. Typically, the State regulation specifies which licensed personnel cannot count towards the ratio (usually the DON, and sometimes the ADON, the nurse educator, and other supervisory personnel). Maryland describes how to count ward clerk personnel into the overall ratio at 50% of time provided in nursing units. Some States—e.g. Georgia, specify that dining assistants not be counted in the ratio; Vermont specified that activity staff and meal preparation staff do not count, whereas other States seem to take that for granted. Maine specifies that private duty nurses are not included in calculating the ratio. Some States specify adjustments that can be made to reduce the nursing-staff-to-residents ratio if the residents attend other treatment programs during the day—a circumstance more likely for residents in mental retardation or developmental disability facilities or special mental health programs. Indianarequires a ratio requirement for licensed staff only. Florida established a phase-in process for bringing the staffing ratio up in 3 stages from 2.3 hours of nursing staff per resident day in 2002 to 2.9 by July 2006.

Some states simply specify the total nurse staff ratio, for example, 1.5 total hours per resident per day in Louisiana, 2 hours per resident in Minnesota,2.5 hours direct care and treatment staff per resident per day in Delaware, 2.7 hours per resident in Pennsylvania, 2.8 hours per resident in Mississippi, and 3.0 inCalifornia and Vermont.More commonly States specify the proportion of the hours that must be fulfilled by licensed personnel as opposed to CNAs; for example, Iowa requires 2 hours per resident day, 20% of which is licensed staff. The notion that 20% of the nursing time be supplied by licensed staff is a common formula; after the elaborate case-mix adjusted formula of New Jersey is applied, then 20% of the hours must be fulfilled by licensed staff. Some States establish their instructions slightly differently; for example, Georgiacalls for 2 hours direct nursing per patient day, and states that for every 7 total nursing staff, 1 must be RN or licensed nurses. Sometimes States provide elaborate instructions for how to calculate the ratio, and also specify that it is the ratio of actual hour worked rather than hours scheduled that shall be counted. In a requirement that seems somewhat ambiguous, Kansas calls for a minimum of weekly average of 2.0 hours of direct care staff/resident and a daily average of no less than 1.85 hours/24 hour period.

Several states require different ratios for different levels of care (e.g., SNF versus ICF or various levels recognized by the State. New Jersey offers a particularly complex formula whereby varying additional time is added to the basic nursing staff-to-resident ratio for each resident who needs any of a number of nursing procedures.

At least 9 States specify or suggest the ratios per shift. New Mexico offers suggested ratios by shift and Illinois gives a desirable range for each shift, allowing for some facility variation—i.e., at least 40% of the minimum required hours shall be on the day shift, at least 25% of the minimum required hours shall be on the evening shift, and at least l5% of the minimum required hours shall be on the night shift. Illinois’ staffing provisions are adjusted by case mix and quite complex, with additional variations for facilities with more than 250 beds. Others state provide the specific ratio required for each kind of personnel by each shift (Connecticut, Michigan, Oklahoma, Oregon, and South Carolina). Some States merely refer to day, evening, and night shifts, whereas others actually provide the time periods for those shift; Connecticutdistinguishes between staffing from 7 a.m. to 9 p.m. and 9 p.m. to 7 a.m., although these times might cross shifts. South Carolina refers to 3 shifts, but then explains how to calculate ratios if the facility is using 12 hour shifts. Montana and West Virginia provide tables to indicate the minimum number of staff members of each type of training to be slotted into each shift. Montana’s provisions are particularly elaborate. [NH Regs Plus Comment: The elaboration of staffing ratios per shift has the perhaps unintended effect of fixing the conventional 3-shift pattern, and, in some cases, even the timing of those patterns and discouraging alternative ways of staffing. This may be contrary to the individualization of shifts seen in some facilities in the midst of culture change—either the creation of unconventional shifts, or even the individualization of shifts for particular works so as to create a greater presence at peak times of activities. If each staff member’s day, evening, and night shifts are construed somewhat differently, compliance with shift-specific staffing ratios is difficult. Obviously States that provide overall ratios per-resident-per-day offer the facility more opportunity to creatively organize staff to meet resident needs. Further, it should be noted that there is an absence of any empirical data to support staff complements that are higher between 7 a.m. and 3. pm., say, than between 3 pm. and 11 a.m.]

Several States add a caveat that notwithstanding the mandated ratios, the State may require additional staff. Massachusettsstates that the minimum staffing patterns and nursing care hours as contained herein shall mean minimum, basic requirements. It anticipates that additional staff will be necessary in many facilities to provide adequate services to meet patient needs. Illinois anticipates “occasional differences of opinion between facility staff and Department surveyors regarding the level of care an individual resident may require” because the ratio is calculated based on assessments of level of care needs. The rules require that when such differences occur, the surveyor shall determine whether or not the resident is receiving appropriate care. If the resident is, the surveyor shall accept the facility's level of care determination in determining the number of nursing hours to be provided by the facility. In Kansas, the licensing agency may require an increase in the number of nursing personnel above minimum levels under certain circumstances, including: (i) location of resident rooms; (ii) locations of nurses' stations; (iii) the acuity level of residents; or (iv) that the health and safety needs of residents are not being met. In Nebraska, based upon the physical layout of the nursing facility, the licensing agency may increase the nursing care per resident ratio.

The States also allow for lowering the required ratio. For example, in Maryland, facilities not participating in Medicare or Medicaid and with 40 beds or fewer may request an exception to the required staffing. If it discerns no hazard to residents, the Department may grant such exceptions based on information that includes; 1) Size of the facility; (2) Geographic location of the facility; (3) Admission policies of the facility; (4) Existing staffing pattern of the facility; and (5) Number of volunteers in the activity program.

Wisconsin enunciates a more permissive policy towards counting non-nursing staff in nursing ratios. In Wisconsin, when determining staff time to count toward satisfaction of the minimum nursing service hours in this section, the follow­ing duties of non−nursing personnel, including ward clerks, may be included: a. Direct resident care, if the personnel have been appropri­ately trained to perform direct resident care duties; b. Routine completion of medical records and census reports, including copying, transcribing, and filing; c. Processing requests for diagnostic and consultative ser­vices, and arranging appointments with professional services; d. Ordering routine diets and nourishments; and e. Notifying staff and services of pending discharges. On the other hand, no services provided by volunteers may be counted toward satisfaction of nursing staff requirements.

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope. The Table summarizes content on Staffing Ratios by State (with a link to each State's specific language). Link to a downloadable PDF document containing all State requirements on Staffing Ratios.

In chronic and convalescent nursing homes: at least .47 per resident per day licensed nursing 7 a.m. to 9. p.m. and .17 licensed nursing per resident per day 9 p.m. to 7 a.m.; at least 1.40 total nursing per resident per day 7 a.m. to 9 p.m. and .50 total nursing pr resident per day 9 0p.m. to 7 a.m. ; in rest homes, at least .23 licensed nursing per resident per day from 7 a.m. to 9. p. m and .08 licensed nursing per resident per day from 9 p.m. to 7 a.m., and at least .70 total nursing per resident per day 7 a.m. to 9. p.m, and .17 total nursing per resident per day from 9 p.m. to 7 a.m.

Minimum CNA staffing of 2.3 hours of direct care per resident per day beginning January 1, 2002, increasing to 2.6 hours of direct care per resident per day beginning January 1, 2003, and increasing to 2.9 hours of direct care per resident per day beginning July 1, 2006. Beginning January 1, 2002, no facility shall staff below one CNA per 20 residents, and a minimum licensed nursing staffing of 1.0 hour of direct resident care per resident per day but never below one licensed nurse per 40 residents.

In SNFs, there must be 2.5 hours nursing staff per resident day, 20% of which is licensed nurses; in ICF regular, 1.7 hours nursing staff per resident day, 20% of which is licensed nurses; for ICF light, 1 hour nursing staff per resident day, 20% of which is licensed; staff must be deployed at least 40% of minimum hours on day shift; at least 25% on evening shift; at least 15% on night shift; additional elaborate instructions on how to calculate; additional staffing requirements.

Minimum of weekly average of 2.0 hours of direct care staff/resident and a daily average of no less than 1.85 hours/24 hour period. 1 licensed nurse staff member for 30 residents, but must have as many licensed nurses as nursing stations; DON may count if under 60 beds.

Kentucky

No

Kentucky regulations do not contain specific content for staff ratios.

2.0 hours bedside care per licensed bed per day, 7 days per week. Ward clerk hours computed at 50% of time provided in nursing unit; DON included if provision of bedside care is documented. No less than 1 nursing personnel to 25 residents.

Minimum of 1 staff member is required for safety and protective oversight to residents at all times (around the clock); 1 additional staff person is required during specific periods when the number of residents require it.

Table provided for number of RNs, LPNs, and CNAs required for each shift by size of facility. The number of RNs required exceeds the federal minimums, and specific numbers of CNAs and LPNs are also required for various shifts and facility sizes.

If any SNF care is offered, 2.5 total nursing staff required per resident per day; in ICFs 2.3 hours per resident day; both calculated on 7 day average. Suggestion that for SNFs, actual staffing might approximate 1.8 hours per resident on day shift, 1.1 on evening and 1.13 on nights. For ICF, 1.7 for days, 1.1 for evenings, and 1.12 for nights is suggested.

New York

No

New York regulations do not contain specific content for staff ratios.

3.0 hours total care staff per resident day, calculated weekly, including nursing care, personal care and restorative nursing care, but not including administration or supervision of staff. Of the three hours of direct care, no fewer than 2 hours per resident per day must be assigned to provide standard LNA care (sic) (such as personal care, assistance with ambulation, feeding, etc.) performed by LNAs (sic) or equivalent staff and not including meal preparation, physical therapy or the activities program.

Virginia

No

Virginia regulations do not contain specific content for staff ratios.

Washington

No

Washington regulations do not contain specific content for staff ratios.

2.25 total hours per day for residents in need of skilled nursing care; 2.0 total hours for resident in need of intermediate nursing care; 1.25 hours of nursing personnel/day/resident in need of limited nursing care, 20% provided by licensed nurses; 0.5 hours of patient care personnel/day/resident in need of personal care.